Eating Disorder and Sexual Compulsivity: Commonalities in Syndromes

by Mark F. Schwartz D.S

I. Introduction

The purpose of this paper is to discuss similar pathognomonic features of eating disorders and sexually compulsive/sexually anorexic behaviors, and reasons for this frequent comorbidity. Recognizing the similarities between these two disorders can facilitate the understanding, development, and treatment of both. The common features the disorders share include polarizations in the following areas:

Each is characterized by over-controlling, contributing to out-of-control behavior of a natural function.

Each serves as a manifestation of impulsivity and compulsivity related to post-traumatic stress and affect regulation, as well as a means to cope with anxiety.

Each unfolds in the absence of a true self and instead, is marked by a lack of self-cohesion resulting in disassociated and polarized parts of the personality.

Each evolves as the result of disorganized attachment and resultant inability to utilize self or others as a resource for self-soothing, comfort, or affect regulation.

Each allows for the reenactment of childhood core schemas related to shame and powerlessness.

Each provides an illusion of control while engaging in behaviors when, paradoxically, the individual is out of control.

Each can be a manifestation of “trauma-based” reenactments.

Each affords the individual an opportunity to be “seen” for being special or sick, while simultaneously allowing her to stay invisible.

Each is fueled by fears of vulnerability, rejection, and abandonment, and distinguished by selective abstraction of feedback.

Each results in feelings of both numbing and hyper-arousal from acting-out.

Each affords a way of negotiating boundaries, thereby maintaining identity.

Each translates into “Russian roulette,” or flirting with self-punishment, self-injury and sometimes suicide.

These features will be reviewed subsequently.

II. Hyposexuality/Hypersexuality

Sexual desire is a complex multifactorial developmental system and little has been published that provides conceptual base for its examination (Schwartz, 2009). As Kaplan (date) defined, hyposexuality implies that the sexual response is consistently inhibited and, most often, is accompanied by low initiatory behavior. Conversely, hypersexuality is the result of a low threshold for sexual responsiveness, often with obsessive-compulsive rituals of sexual expression that displaces the passionate attachment with the partner. The rituals may also revolve around masturbation, paraphilia, or cybersex rather than partnered sex. These substitutes are frequently associated with excessive shame and an emphasis in relief of anxiety or tension; they can become addictive-like, with a duality involving both over-control and out-of-control, restrict and binge aspects that clinically seem to represent “two sides of the same coin,” each with common underlying organizing features of fears of intimacy.

Like addiction, the individual can experience tolerance and withdrawal from behaviors as well as an indifference to the consequences. Also, the activity is used to alter mood, thereby becoming a form of affect regulation. Increased dopamine, glutamate, and GABA levels over activate the “go” switches, suggesting a common biochemical thread (Inaba, et al., 2007).With sexual compulsivity, sex is the person’s most important all-consuming activity, characterized by excitement in anticipation of acting-out, followed by a rapid drop into shame, similar to the cycle experienced by abusers of “crack.”

Often, individuals are labeled or label themselves as hyposexual or hypersexual, and the pattern becomes a dispositional trait or personality characteristic engraved into their sense of self. Other characteristics may cluster around the central trait. These include impulsivity, rule-breaking, sensation-seeking (hypersexuality) versus rigidity, constrictaory, over-controlling, distancing from others, and withdrawing into self (hyposexuality). In relationships, the individual can be labeled as hyposexual, and the deprived other often appears to compulsively desire sex with escalating polarization occurring until the labels become entrenched and antithetical extremes. One individual can become obsessed with wanting that which they cannot have, equating rejection of sex as “not caring about or loving the other” (Schwartz and Masters, 1975).

Sexual arousal and desire also define and are defined in the relational context. The experience of “falling in love” is often accomplished by hypersexuality, whereas, relational boredom, fatigue or hostility results in hyposexuality in healthy individuals. Sexuality can mediate and modulate closeness and distance as the relationship progresses, and become a manifestation of fears of intimacy. An individual can initiate sex to avoid intimacy or to solicit greater closeness when perceiving distance.

Hyposexuality is most often used to describe individuals who do not have desire for sex with their romantic partner. However, sexual desire can be secondary to vaginismus, rapid ejaculation, impotence, anorgasma, or other dysfunctions. In such cases, treatment of the sexual dysfunction usually reverses the desire-phase disorder.

Eating disorder is the final common pathway to many developmental trajectories. Eating disorder involves obsession with thoughts of food and use of food to escape undesirable thoughts or feelings such as depression or anxiety. Overeating can be considered a food addiction because certain foods alter the brain in ways that intensify cravings similar to psychoactive drugs and sexual compulsion (Inaba et al., 2007), and can result in fewer dopamine receptors in the nuclear accumbens (Levine et al., 2005). Anorexia, the restricting of food intake, and bulimia, eating large amounts of food in one sitting (bingeing), followed by attempts to prevent weight gain, are frequently intertwined in the same individual over time.
Common to clients with eating disorders are other characteristics of obsessive- compulsive disorders. Common traits of detesting weakness and repudiating “needs” are more frequently found in women. She either envisions herself as an “adult” even in childhood, or is detached from the child she was, with little self-empathy or self-compassion. She protects herself through rituals revolving around food, cleaning, achievement, caregiving, self-deprivation and continually achieving for others (Schwartz and Cohn, 1995). The anorexic feels she is taking up “too much” space and resources of which she feels undeserving. She feels empty but will not accept nourishment—either physically or emotionally—and “won’t keep” what she does take in. Pleasure is anathema or must be paired with self-degradation. Others are viewed as competitors, would-be critics, and potential sources of disappointment who must not see what lies within the eating-disordered individual.

IV. 1.0 Over-control/Out of Control

Both hunger and sexual desire are subject to some voluntary control, influenced by internal and external cases, and are greatly susceptible to emotions such as anxiety, fear, and aloneness. Sometimes fear of sexuality and intimacy influence the development of an eating disorder, and eating disorders can displace the need for relationships (Schwartz, 1996). Thus, intimacy disorder, or the feeling of aloneness when surrounded by people, or the inability to utilize others as a source of comfort can cause problems with food and sexuality. When clients who binge establish some control, their anorexia frequently takes over, and when hypersexual individuals become abstinent, they often become hyposexual. In both disorders there seems to be a primary problem with affect-regulation, self-differentiation, and attachment difficulties which underlie the symptoms.

V. 2.0 Affect Regulation

Emotions can become dissociated such that when one is sad, lonely, or fearful, for example, they can attempt to bypass the experience and instead replace it with hunger or sexual preoccupation. Acting on addiction can be numbing, which also suppresses emotions. The temporary suppression of an emotion obliterates the signal function for action to reduce the distressing state, thereby resulting in potentially greater distress and the need for more addictive behavior. The solution becomes both necessary and distressing in itself. Also an inability to process stress in a functional manner results in multiple problems and chronic distress.

Where there is a history of trauma, abuse, or neglect, people who might be a source of comfort may also become the source of distress. The featured individual overgeneralized that people are a source of danger. Herman notes that “abused children discover they can produce ‘release’ through emotions becoming dysregulated,” so that autonomic nervous system hypersecretes cortisol and they then experience intense reactions that they discover can be quelled by food, sex, work, and so on. Boys seem to more commonly find the solution in sex, while girls turn to food. Both form chaotic relationships, re-creating and reenacting the familiar early abuse and neglect with peers. Purging, compulsive sex, and risk- taking thereby become vehicles through which abused children accidentally discover how to regulate their internal state. They continually attempt to over-control and are then compulsively driven to release. This results in painful interactions with others that simply accentuate the cycle. Crittenden (1988) suggests that affect suppression leads to a greater likelihood of dismissive attachment styles, leading to over-control of appetite for food or sex. Affect exaggeration is more often related to preoccupied or anxious attachment, clinging and dependency, which is subsequently related to excessive food intake and dependency on partners. Typically, clients cycle between relational, food, and sexual bingeing and restricting—as one goes up, the other goes down. The individual overrides his or her “natural appetite” and natural functions to maintain and perpetuate cycles of distress.

VI. 3.0 Self-Development

The individuals with both eating and sexual disorders often state that they feel like imposters. Absence of attachment attunement during the first year of life lead to self-cohesion difficulties, leaving the individual vulnerable to fragmentation (Sroufe).This becomes evident later in life. For example, the individual who attends school and performs as a “good student,” then returns home to an absent family structure. Without basic integration of these self states, they experience contradictory affects—i.e., “I’m bad, but I care for others” or “I’m unlovable, but friends seem to love me.” This inconsistency eventually leads to a states of extreme dissociation — a priest can molest and a “good girl” can refuse to eat, a “loving husband” can have an affair. Without self-constancy (which is cemented by age three) the individual becomes over-reliant on others to define his or her identity. In this state of confusion, the eating or sexual disorder can become interwoven into their identity, functioning to bind the anxiety from the continual internal contradictory affect and cognitions.
By age four, a child develops self-agency, or the ability to operate in the world and actively create or elicit responses from others (Brown). A child develops a lexicon for affect and forms a framework for self-efficacy and masking. Both food addicts and sex addicts often lack a sense that they can take variable actions to solve problems. With so many emotionally charged situations out of their control during childhood, they adapted with a sense of learned helplessness. The result is a high susceptibility to influence and an inability to trust their sense of mastery.

VII. 4.0 Attachment

Emerging data suggest the importance of using the lens of attachment theory to understand both eating and sexual disorders. Adult capacity for pair-bonding, courtship, attraction, affection, and intimacy are all influenced by the blueprint of the attachment with caretakers in the first several years of life. Without adequate parenting, the child will later grapple with increased appetite for nurturing and caretaking, while simultaneously adapting to become “dismissive” of such needs, developing expectations of disappointment, abandonment, rejection, or abuse. “Needs” become dangerous and are associated with fear, which is the core structure for the development of psychopathology. “Not needing” translates into not eating or becoming increasingly small and invisible. Similarly, not needing a partner leaves the door open to developing sexual arousal to objects, turning to paraphilia, or some other displacement for affection that is perceived as safe. Cybersex, for example, creates a safe distance between one and the partner.
When individuals experience misattunement with their caretakers during infancy, they fail to establish secure attachment and the accompanying feelings of worthiness of love and affection. This leaves the individual vulnerable to food or sex, displacing the natural instinct to pair-bond. The early attachment templates shape core schema, distorting information coming in from others. These dynamics alternately shape an individual’s range and type of interactions, driving relational and intra-relational reenactments (Lamagna and Gleiser, 2007).
Such repetitive predicaments leave the individual feeling the shame, helplessness and self-doubt they experienced in childhood or adolescence, a form of “affective flashback.” The individual feels rejected or fat, and wants confirmation of lovability but believes only food or sex can fill the inner emptiness. But orgasm or bingeing only fill the emptiness temporarily, followed by a rapid drop to more intense aloneness.

Additionally, close relationships require developmental rehearsals and skill acquisitions related to saying yes or no, asserting one’s needs, expressing interests and desires separate from that of the partner, and use of touch and conversation with appropriate self-closure. All these social interactions seem developmentally delayed in eating-disordered and sexually compulsive clients, which becomes painfully clear once they maintain some control of these symptoms. Practicing such skills in psychodrama is critical to overcome situations that trigger relapse.

VIII. 6.0 Feeling of Power When Enacting

Other structural defects resulting from neglect include (1) the inability to recognize internal states and represent them with effect on words, (2) the use of such states to take action or problem solve through communication, (3) the ability to read cues from others for self-care and safety, and (4) the ability to establish control of emotional states effectively to act on one’s short-term and long-term best interest. The absence of those structural capacities results in repeated frustration, disappointment, hurt and anger, which then fuels further impulsive/compulsive behavior. The resulting helplessness and powerlessness leads to self-hatred and self-injury, which, in turn, fuels the vicious negative cycle. By acting out on her addictive behavior, the individual has an illusion of perceived control, an escape from the distress and ineffectuality and a distraction from their powerlessness.
Another area in which this perceived powerlessness is related to sexual behavior is with a partner. Often, both the eating-disordered and sexual anorexic client will bypass this lack of desire or phobic response to sexual interaction and then pressure or guilt themselves to perform sexually, causing an aversion-reflex to sex which resembles an actual phobia. The use of systematic desensitization is remarkably effective in reversing this problem, but finding a cooperative partner can prove difficult.

As is the case with eating-disordered clients, at some point, the individual receives the external pressure of guilt, which results in forcing themselves to eat, which can potentially set up a similar reflex. Thus once the individual learns not to panic under pressure, but to reinstate full self-control over how and how much, treatment of the fear is very effective in allowing a sense of mastery to generalize.

IX. 7.0 Trauma-Based Reenactments

Complex trauma and Post-Traumatic Stress Disorder in childhood often result in individuals developing symptoms as a means of communicating that something on the “inside” doesn’t match the “outside.” The symptoms become a “trauma-bond,” linking the unfinished business from the past with the present.

The difficulty in most cases is that the trauma has been sequential throughout the childhood/adolescent years with complex trauma, and therefore, underneath one piece of trauma lies another. Symptom remission is tied to resolution of multiple developmental traumas. The second problem is that traumatic memories are tied to subsequent overwhelming experiences. For example, most clients who were sexually abused find that full resolution of the abuse memories are linked to their ambivalent feelings regarding their mother not protecting them and/or abandoning them. Thus, in addition to the post-traumatic stress, there are early-misattuned attachment difficulties compounding the response to abuse. Resolution typically involves working on the attachment issues and the sexual abuse.

The most challenging aspect of trauma resolution is accessing the traumatic memories and cognitions specifically involved in creating or maintaining symptoms of anorexia and bulimia. Typically, the work begins by showing a mental image of the injured child and allowing her to express affect and her perceptions of the world. Often, “leading-edge” feelings emerge and can be re-associated to their original cause. For example, the client might write about her worst eating disorder day in detail and read it out loud. When she expresses the emotions of horror and sadness she is instructed to follow those feelings back in time to any event that might have contributed to such behavior or emotions, or perhaps a time in the past where she felt similarly. Utilizing EMDR (Shapiro,) and Internal Family Systems (Schwartz, 2007) allows for resolution of the “big T” (trauma) as well as “smaller t’s”, also tied into the symptom. Often the symptom is tied to idiosyncratic past events that surprise the client.

Another requirement of effective trauma work is that the adult-self is present with the injured-self and that they form an internal relationship in imagery. The injured self can then express the memories with internal pictures and words that were not fully expressed at the time with the assessment of the adult-self and feel “witnessed” (Schwartz, 2007). It seems like any overwhelming events need to be fully expressed and witnessed by self and others to be fully integrated. Children are ill equipped to do this without a parent or therapist in assistance. The injured-self also verbalizes beliefs that were engendered by the trauma, i.e. “I am bad”, “others will hurt you”, and the schema or core beliefs around power, control, esteem, trust, and intimacy and how each contribute to the eating disorder or sexually compulsive symptoms—“I need control of what I put into my body or over other people to feel safe”. In this way unconscious contradictory factors are made salient and thereby lose their power. The injured-self must then talk to the healthy adult-self to correct the maladaptive beliefs.

X. 8.0 Need To Be Seen for Being Special or Sick

The original cause of a symptom can be different than factors that maintain and perpetuate it. On the outside a person can appear okay to others, while feeling inside tremendous distress. They may appear competent and happy in their relationships while their outer appearance becomes so discordant from their inner distress that they feel compelled to sabotage their success by resigning their job or having an affair. Similarly, having a secret life in which they purge and illicitly look at sexual content on the internet seems to balance the discordance from their appearing “good” while feeling “bad”. The more good things that happen, the more there is a need for balance by taking greater risks; i.e., tolerance increases for acting out, and they take greater risks of being exposed which can be experienced as relief. Thus, having a secret life becomes functional and seems to allow for external successes.
Related to this eating disorder is frequently recounted as a disorder of extreme neglect and learning as a child that being sick elicits attention the child craves. As an adult, feeling disconnected and alone elicits the desire to act out or be sick to feel “cared-for”.

XI. 9.0 Fear of Vulnerability, Rejection, and Abandonment from People

One of the structural defects of early abuse and neglect is misinterpreting affect-defining gestures and verbal responsively from others. Their obsession is not disappointing others which becomes a tyranny such that they organize their behavior in perpetual anticipation of anxiety and resultant perfectionist pursuit for perceived successes. The result is a narcissistic-seeming appearing pattern of continual self-focus — they do for others so others will not reflect or disapprove of self. If one individual disapproves of dislikes, they experience self-flagellation.

This symptom is actually quite difficult to therapeutically reverse. It stems from an absence of a secure attachment with self, and an unwillingness to accept Ellis’s first cognitive distortion, “You will not like all people and they will not all like you.” In order to reverse this cognitive distortion the therapist needs to “seed” the development of a “real-self”. Characteristics of the real-self defined by Masterson (2000) are listed in Table 1. This requires internal communication between injured parts of self with a healthy adult-self, coached by the therapist. The self-witnesses early experiences that shaped core negative beliefs about self (“I am bad; others will hurt you”) and learns how each contribute to the compulsive behaviors. Thus, unconscious contributory factors are made explicit. By systematically questioning these beliefs, they are revisited and potentially lose their power. This is followed by coaching new ways of perceiving and acting on an ongoing basis.

XII. 10.0 Feelings of Both Numbing and Hyper-Arousal From Acting-Out

Addiction is often a tool to numb, when beginning to think and feel, and to experience highs that allow individuals to know they are alive when feelings of depression, numbness, emptiness, and physical and emotional analgesia pervade. The body of a sexual addict can become analgesic related to early trauma (van der Kolk, 1989). Similarly, the release of opiates, and inflicting bodily harm by binging , purging, starving, cutting, head-banging, hair- pulling, prostituting can create a release that seems to help cope with the inner emptiness, or to just feel something through the fog of dissociative numbing. Destructive eating and/or forced sex can create a sense of safety or connection for an individual with a dissociative disorder. Such behavior can also result in a feeling of perceived control when feeling out of control—“This time I’m doing it to myself!”

The need for sensation-seeking or conflict with others can also, paradoxically, provide relief from the inner emptiness and boredom accompanying classic dissociation and fragmentation of the self-system. Physiologically, the individual resembles the opioid addict who can register pleasure and happiness from enjoyable experiences only when also taking a drug such as cocaine. Following inescapable stress, the brain does not seem to respond to pleasurable situations normally (van der Kolk, 1989). The threshold for pleasure is elevated and continually rises, more is required to temporarily escape emptiness. Thus relapsing creates a crisis and caretaking or nurturing for others provides secondary gain for symptoms.

Discussion- It has been our clinical experiences that clients will present with a process addiction related to food, and minimize their history of sexual issues, or present with hypo and hyper sexuality—while minimizing their issues with food. Each of their problems tend to be chronic, difficult to get under control, and tied to numerous past unresolved contradictions and also are maintained by current triggers and stresses. For this reason, our approach is to work on Relapse Prevention to attain some temporary control and then to look at resolve, give insight and suggest alternative cognitions and behaviors related to some of the continuing and maintain functions of the symptoms until alternative more functional solutions are established